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Portal vein thrombosis

Key sources
The following summarized guidelines for the evaluation and management of portal vein thrombosis are prepared by our editorial team based on guidelines from the American Society of Hematology (ASH 2023), the European Association for the Study of the Liver (EASL 2023; 2016), the American Association for the Study of Liver Diseases (AASLD 2021), the European Federation of Societies for Ultrasound (EFSU 2020), and the American College of Gastroenterology (ACG 2020).
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Guidelines

1.Screening and diagnosis

Clinical presentation
Assess for the possibility of acute PVT in any patient with abdominal pain.
A
Assess for the possibility of intestinal infarction in patients with severe and persistent abdominal pain, rectal bleeding, moderate or severe ascites, or multiorgan dysfunction. Monitor these patients closely for signs of deterioration.
B
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2.Classification and risk stratification

Prognosis: insufficient evidence whether PVT in patients with cirrhosis is merely a reflection of progressive portal hypertension or independently causative of increased mortality, outside of liver transplant candidates.
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3.Diagnostic investigations

Diagnostic imaging: as per AASLD 2021 guidelines, ensure a standardized documentation of initial site, extent, degree of luminal obstruction, and chronicity of clot formation in any patient with PVT, in order to make objective serial assessments of spontaneous regression or treatment response.
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  • Evaluation for underlying causes

4.Medical management

General principles: obtain immediate consultation with surgery, critical care, interventional radiology, and hematology in all patients with recent PVT and concern for intestinal ischemia. Initiate anticoagulation. Proceed to surgery in cases of intestinal infarction.
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  • Indications for treatment

  • Indications for anticoagulation (non-cirrhotic PVT)

  • Indications for anticoagulation (PVT in cirrhosis)

  • Choice of anticoagulation

  • Duration of anticoagulation (testing for thrombophilia)

  • Duration of anticoagulation (non-cirrhotic PVT)

  • Duration of anticoagulation (PVT in cirrhosis)

  • Management of underlying causes

5.Therapeutic procedures

Endoscopic variceal ligation: consider performing endoscopic vatical ligation without stopping therapeutic anticoagulation. Initiate anticoagulation as soon as possible and not delayed until variceal eradication or adequate β-blockade is achieved.
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  • Portal vein recanalization

  • TIPS

6.Specific circumstances

Pregnant patients: counsel female patients with vascular liver disease that the condition is associated with preterm birth and operative delivery.
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7.Follow-up and surveillance

Follow-up
Obtain CT to assess recanalization of the portal venous system at 6-12 months follow-up.
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Screen for gastroesophageal varices in unrecanalized patients.
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